infant feeding and prescribing guidelines · when onward referral to dietetic or paediatric...

Infant Feeding and Prescribing Guidelines Version: 1.0

Date: 21 June 2018

Written by: Julie Nicol, Louise McKerrow, Dr Paula Young and Dr John Morrice Review: June 2019

Infant Feeding and Prescribing Guidelines

A guide for healthcare professionals working in primary care

These guidelines aim to provide information on dietary related clinical conditions and the appropriate use of specialist infant formula. They advise on:

Post-discharge formula for pre-term and growth restricted infants, Faltering growth, Gastro-oesophageal reflux, Secondary lactose intolerance and Cow’s milk protein allergy

Which products to prescribe for different clinical conditions

Quantities to prescribe

When an over- the- counter product is available and appropriate to use

Triggers for reviewing and discontinuing prescriptions

When onward referral to Dietetic or Paediatric services should be considered

Breast feeding provides the optimum nutrition for healthy infants however these guidelines are intended for use for infants who require or are already prescribed a specialist infant formula.


Date: 21 June 2018


Acknowledgements We would like to thank our colleagues who kindly commented on this document: Dr Sean Ainsworth - Consultant Neonatologist

Evelyn Gambier - Paediatric Dietitian

Laura Logan - Paediatric Dietitian

Alison Macleod – Clinical Lead Paediatric Dietitian

Michelle McBurney – Paediatric Pharmacist

Linda McGourty – General Practitioner

Elizabeth Muir – Clinical Effectiveness Coordinator

Janet Purves - Paediatric Dietitian

Euan Reid – Senior Practice Pharmacist

Sally Tyson – Lead Pharmacist


Date: 21 June 2018


Contents Page

Page No.

Quick Reference Guide

4

Guidance on feed volumes and volumes to prescribe for infants

5

Guidance on prescribing, reviewing and stopping formula

1. Post-discharge formula for preterm and growth restricted infants

6

2. Faltering Growth 7

3. Gastro – oesophageal Reflux 9

4. Secondary Lactose Intolerance 12

5. Cow’s Milk Protein Allergy 13

Additional Resources 14

Appendix 1 - Referrals to Paediatric Dietetic Department 15

Appendix 2 – Drugs used for Gastro-oesophageal reflux 16

References 17


Date: 21 June 2018

Written by: Julie Nicol, Louise McKerrow, Dr John Morrice and Dr Paula Young Review: June 2019

4

Quick Reference Guide

Below is a summary of the main recommendations. Please refer to the document for further information on specific clinical conditions. Promote and encourage breastfeeding where it is clinically safe. Check the amount of formula prescribed is appropriate for the age of the infant and/or refer to the most recent documentation from the Paediatric Dietitian. Review any prescriptions where the child is over 2 years old, the formula has been prescribed for more than one year, or greater amounts of formula are being prescribed than expected. Prescribe only one or two tins initially until compliance/patient acceptability is established to avoid waste unless otherwise directed by a Paediatric Dietitian. If a child is started on a formula in secondary care it is recommended that GP’s do not initiate changes of formula unless requested by a Paediatrician or Paediatric Dietitian. Preterm and growth restricted infants (Page 5) • Stop post-discharge preterm formula at 6 months corrected age (6 months + no. of weeks prematurity) and change to a standard term formula. Refer to a Paediatric Dietitian if there are concerns regarding weight gain. Faltering growth (Page 6) • Refer to a Paediatrician and Paediatric Dietitian if there are concerns regarding weight gain. Gastro- oesophageal reflux (Page 8) • Do not use a thickened formula for more than 6 months. • Thickened formula should not be used with separate feed thickeners e.g. Gaviscon infant, Instant Carobel. Secondary Lactose intolerance (Page 11)

• Lactose free formula should not be prescribed. • Parents/carers should be encouraged to purchase an over the counter lactose

free formula or buy a lactose free milk from the supermarket if the child is over 1 year of age.

Cow’s Milk Protein Allergy (CMPA) (Page 12)

Remember to follow CMPA pathway Do not prescribe lactose free or soya formula for CMPA


Date: 21 June 2018


5

Guidance on Expected Weight Gain for Infants

Boys (grams per week) Girls (grams per week)

0 – 3 months 240 210

4 - 6 months 130 120

7 - 9 months 80 75

10 - 12 months 65 60

(Clinical Paediatric Dietetics, 2015)

Guidance on Feed Volumes to Prescribe for Infants

Age Volume ml (oz) Suggested intake per day Equivalent in

tins per month

Up to 2 weeks 60-70ml

(2-2 ½ oz) 7-8 feeds 150ml/kg

12 x 400g

2 – 8 weeks 75-105ml

(2½ - 3½ oz) 6-7 feeds 150ml/kg

12 x 400g

2 – 3 months (9-14 weeks)

105-180ml (3 ½ -6oz)

5-6 feeds 150ml/kg

12 x 400g

3 – 5 months (15-25 weeks)

180-210ml (6 – 7oz)

5 feeds 150ml/kg

12 x 400g

6 months (26 weeks)

210-240ml (7 – 8oz)

4 feeds 120ml/kg

12 x 400g

General guidance on feeding after 6 months

7 – 9 months About 600ml

per day

Infant formula could be offered at breakfast (150ml), lunch (150ml), tea (150ml), and

before bed (150ml)

12 x 400g

10 – 12 months

About 400ml per day

Infant formula could be offered at breakfast (100ml), tea (100ml), and before bed

(200ml)

10 x 400g

1 – 2 years

About 350 – 400ml per day of full fat cow’s milk or another

suitable alternative.

Full fat cow’s milk could be offered at snack times twice per day (100ml x 2), and as a

drink before bed (200ml)

8 x 400g

(First Steps Nutrition Trust, 2017)


Date: 21 June 2018


6

Guidance on Prescribing, Reviewing and Stopping Formula

Condition/Indication Pre-Term Infants

Diagnosis Preterm and growth restricted infants who are not breastfed are commenced on a nutritionally enriched formula1. If these infants are growth restricted at discharge, they should be prescribed a post-discharge nutritionally enriched formula. NOTE: These formula should not be used in primary care to promote weight gain other than for those born prematurely

Treatment/Review Criteria

Any infant discharged on these formula should have their growth (this includes weight, length and head circumference) monitored by the Health Visitor as well as attending their neonatal follow-up. If there is any concern regarding an infant’s growth, a referral should be made to Paediatric Dietetics. Infants receiving 150ml/kg/day preterm formula do not require additional vitamin or mineral supplementation1.

Name of Formula SMA PRO Gold Prem 2 or Nutriprem 2

Age Use up to 6 month corrected age (i.e. six months plus the number of weeks prematurity added on).

Criteria for Stopping Formula

Up to 6 months corrected age. These formulas should be stopped if there is excessive weight gain, as determined by the growth chart centiles3. If there is concerns regarding growth refer to a Paediatric Dietitian. Prescription should not exceed:

NOTE: Please ensure a pre-term feed powder is prescribed and NOT the ready-to-drink pre-term formulas except in exceptional circumstances.

7

Condition/Indication Faltering growth

Diagnosis In the early days of life It is normal for Infants to have some weight loss in the first few days after birth and this is usually due to body fluid adjustments and to allow feeding to be established. By day 5 of life we would expect any weight loss to stop2. Most infants should return to their birth weight by 3 weeks of age. If infants lose more than 10% of their birth weight in the early days of life:

Perform a clinical assessment, looking for evidence of dehydration, or an illness or disorder which may account for weight loss

Take a detailed history to assess feeding

Consider observation of feeding by someone with appropriate training and expertise such as a breast feeding or infant feeding advisor

Perform further investigations only if indicated based on the clinical assessment

Consider using the following thresholds for concern & further assessment in infants and children:

A fall across 1 or more centiles, if birth weight was below 9th centile

A fall across 2 or more centiles, if birth weight was between 9th and 91st centile

A fall across 3 or more centiles, if birth weight was above 91st centile

When current weight is below 2nd centile, irrespective of birth weight

Measure length (from birth to 2 years old) or height (if over 2 years old). Plot measurements on growth chart and any previous measurements to assess weight change and linear growth. The following factors may be associated with faltering growth:

Preterm birth

Neurodevelopmental concerns

Maternal postnatal depression and anxiety

8


In the early days of life: If infants in the early days of life lose more than 10% of their birth weight: Step 1: Provide feeding support

Step 2: If infants have lost more than 10% of their birth weight or they have not returned to their birth weight by 3 weeks of age, consider

Referral to paediatric services if there is evidence of illness, marked weight loss or failure to respond to feeding support

When to reassess if not referred to paediatric services

Infants and children: Consider the reason for weight faltering: Step 1: Rule out underlying medical condition. Refer to secondary care if concerned. Step 2: Check feeding pattern, including food, if weaned. Involve Health Visitors for observation of mealtimes. Consider asking parents / carers to keep a feed or food diary recording intakes (time taken to complete feed, volumes, amounts, types etc.) and any mealtime issues. Step 3: Provide parents / carers with information on suitable high calorie and nutrient dense foods if the infant is weaned (see additional resources on page 14) Establish a management plan with parents/carers with specific goals. Step 4: Refer to Paediatric Dietitian and Paediatrician.

Name of Formula SMA Pro High Energy or Similac High Energy Do not start specialist formulas or ONS unless advised by a Paediatric Dietitian

Age From birth until 18 months or 8kg


All children on high energy specialist formulas or ONS should be reviewed by a Paediatric Dietitian. If a child fails to attend dietetic appointments the specialist milk or ONS should be stopped.


Date: 21 June 2018


9

Condition/Indication Gastro-oesophageal reflux (GOR)

Diagnosis Gastro-oesophageal Reflux (GOR) is the passive transfer of stomach contents into the oesophagus with or without vomiting or regurgitation4. Gastro-oesophageal Reflux Disease (GORD) occurs when reflux of gastric contents causes troublesome symptoms and/or complications. GOR is a normal physiological process occurring several times a day in healthy infants, children and adults. Regurgitation is reported in 23-40% of all infants but reduces in the first year of life to approx 5% of 10-12 month olds. Symptoms and signs of GORD (i.e. more than simple GOR or regurgitation):

Increasing frequency and intensity of regurgitation and/or vomiting

Pronounced irritability with or without back arching

Refusal to feed, pain during feeding or dysphagia

Growth faltering

Haematemesis

Respiratory symptoms e.g. chronic cough, wheeze, recurrent chest infections

Upper airway symptoms

Apnoeas or Acute Life Threatening Events In infants and toddlers there is no symptom or symptom complex that is diagnostic of GORD or predicts response to therapy.


Initial assessment: History and examination to assess for GORD or other diagnosis plus the following: Feeding history

Breast or formula fed

Volume and frequency of feeds

Positioning

Weight and length plotted on growth chart

Urinalysis if history suggestive of UTI Step 1 Parental education and reassurance. Practical advice such as:

Positioning after a feed – prone (face down)


Date: 21 June 2018


10

positioning decreases the amount of acid oesophageal exposure and is proven to improve the symptoms of GOR. (Prone and lateral positions are associated with increased incidence of sudden infant death syndrome and so only encourage “tummy time” when baby is awake).

Elevate the head of the cot by 30°

Avoid overfeeding (take feed history), maximum is 150ml/kg/day if < 6 months old. Ensure appropriate teat is used and avoid excessive air ingestion.

Try smaller more frequent feeds. Step 2 If breast fed If a breast feeding assessment and advice leads to no improvement consider Gaviscon® infant dual sachets (according to the BNFc5 this is not suitable for pre-term infants however the Neonatal Formulary 7th edition6 suggests that it can be used in “proportionate” dose) or use a feed thickener (e.g. Instant Carobel given as a small amount of thick gel before and during feeds – see package instructions) If bottle fed Feed thickener (e.g. Instant Carobel). Alert parents to different procedure for making up feed. Advise them to follow instructions, starting with adding ½ scoop of Instant Carobel to 90ml (3 floz) of formula. Or Suggest over the counter Pre thickened formula (should not be used in combination with other feed thickeners or antacids) Step 3 If vomiting continues along with 1 or more of the following: Unexplained feeding difficulties Distressed behaviour Faltering Growth Then consider the following before or whilst awaiting assessment in secondary care:

1. “Step up therapy” Begin with Ranitidine

Reassess, if inadequate response switch to Proton Pump Inhibitor (PPI) of choice (usually omeprazole MUPS)

Reassess, if inadequate response increase PPI dose


Date: 21 June 2018


11

2. “Step down therapy” Begin treatment with high dose PPI Reassess, if improvement reduce dose PPI Reassess, if improvement switch to Ranitidine

Cow’s Milk Protein Allergy CMPA and GORD often coexist. Many of the clinical features of CMPA are similar to those seen in GORD and it can be difficult to distinguish between the two. See guidance on CMPA

Name of Formulas/ Feed Thickener

Instant Carobel (Cow & Gate) can be spoon fed as paste or added to breast milk or usual infant formula Over the counter Pre thickened formulas can be purchased e.g. Aptamil Anti-reflux (Milupa), Enfamil A.R. (Mead Johnston), SMA Pro Anti Reflux (SMA Nutrition).

Age Most reflux resolves between 10 – 12 months of age.


Review need for Carobel/pre thickened formula if over 12 months old or been prescribed for longer than 6 months

12

Condition/Indication Secondary Lactose Intolerance (LI)

Diagnosis Usually occurs following an infectious gastrointestinal illness. Possible symptoms include: Abdominal bloating Increased wind Loose green stools Secondary lactose intolerance may be suspected but should only be treated if symptoms persist for more than 2 weeks. Symptoms should resolve within 48 hours of excluding lactose. If within 7 days the symptoms are ongoing consider Cow’s Milk Protein Allergy (CMPA). Refer to CMPA pathway7. Primary Lactase deficiency is much less common than secondary lactose intolerance in Scotland. It does not usually present until after 2 years of age.


If breast fed, continue breastfeeding. If formula fed, trial of an over the counter lactose free formula for up to 8 weeks. If the child is over 1 year old lactose free milk can be bought from a supermarket. If the infant is weaned a lactose free diet should also be followed.

Name of Formula Over the counter formula/milk should be advised as first line e.g. SMA LF (SMA Nutrition) or Enfamil O-Lac (Mead Johnson) or if over 1 years old full fat lactose free milk from the supermarket

Age Birth to 1 year


Only use for 2-8 weeks dietary trial. Formula must be reviewed within 8 weeks and stopped or diagnosis of lactose intolerance reviewed. If symptoms return upon commencing standard infant formula then refer to a Paediatric Dietitian for assessment.


Date: 21 June 2018


13

Condition/Indication Cow’s Milk Protein Allergy (CMPA)

Diagnosis Refer to NHS Fife’s Pathway for Infants with Suspected Cow’s

Milk Protein Allergy7.

http://www.fifeadtc.scot.nhs.uk/formulary/9-nutrition-and-

blood/appendix-9b-diagnosis-and-management-of-infants-

with-suspected-cows-milk-protein-allergy.aspx

For mild to moderate non- IgE cow’s milk protein allergy, an

initial trial of an Extensively Hydrolysed Formula (EHF) should

be followed by reintroduction of cow’s milk protein formula

after four weeks to confirm the diagnosis. See Parent Support

Leaflet http://www.fifeadtc.scot.nhs.uk/formulary/9-

nutrition-and-blood/cows-milk-protein-allergy-leaflet-for-

parentscarers.aspx

If symptoms are suggestive of IgE-mediated allergy refer to secondary care.


If symptoms return on reintroduction of standard formula refer to Paediatric Dietetics. All infants on specialist milks for confirmed CMPA should be reviewed by a Paediatric Dietitian.

Name of Formula Nutramigen LGG 1 & 2 Nutramigen Puramino should only be prescribed as advised by secondary care

Age Nutramigen LGG 1 up to 6 months Nutramigen LGG 2 from 6 months. Should not be continued after 2 years old unless advised by a Paediatric Dietitian


Review the need for the prescription if you can answer ‘yes’ to any of the following questions: Is the patient over two years of age? Has the formula been prescribed for more than one year? Is the patient prescribed more than the suggested quantities of formula according to their age? Is the patient prescribed a formula for CMPA but able to eat/drink any of the following foods – cheese, yoghurt, ice-cream, custard, chocolate, cakes, cream, butter, margarine, ghee, cow’s milk? (Cooked milk products are usually better tolerated.) Children with multiple or severe allergies may require prescriptions beyond two years. This should always be at the recommendation of a Paediatric Dietitian.

http://www.fifeadtc.scot.nhs.uk/formulary/9-nutrition-and-blood/appendix-9b-diagnosis-and-management-of-infants-with-suspected-cows-milk-protein-allergy.aspx



http://www.fifeadtc.scot.nhs.uk/formulary/9-nutrition-and-blood/cows-milk-protein-allergy-leaflet-for-parentscarers.aspx




Date: 21 June 2018


14

Additional Resources

Useful Websites

Bliss – for babies born premature or sick. www.bliss.org.uk

BDA The Association of UK Dietitians Food Facts – www.bda.uk.com/foodfacts

Children and Young People’s Allergy Network Scotland (CYANS) NHS Scotland -

www.cyans.scot.nhs.uk

First Steps Nutrition Trust – www.firststepsnutrition.org

Healthy Start - www.healthystart.nhs.uk

Ready Steady Baby! NHS Health Scotland. www.readysteadybaby.org

SARA, Scottish Allergy and Respiratory Academy -

www.scottishallergyrespiratoryacademy.org

Resources Available to Order From The Paediatric Dietetic Department

How can my child avoid anaemia? - A guide for the 0-5’s

Is my child getting enough calcium?

Gaining more control at mealtimes – A guide for the 0-5’s

My child needs to gain weight. What can I do?

Contact Information

Paediatric Dietetic Department Kirkcaldy Health Centre

Whyteman’s Brae Kirkcaldy KY1 2ND

01592 645217

http://www.bliss.org.uk/

http://www.bda.uk.com/foodfacts

http://www.cyans.scot.nhs.uk/

http://www.firststepsnutrition.org/

http://www.healthystart.nhs.uk/

http://www.readysteadybaby.org/

http://www.scottishallergyrespiratoryacademy.org/

15

All Sections MUST be Completed or Referral Will be Returned

If all information can’t be provided discuss with GP who could then initiate a SCI-Gateway referral

Referrer: Name of Health Care Professional, Role, Full Address, Tel No +/or e-mail address

Date Referral Sent: Date Referral Received:

Hospital ________________Ward ________ or Day Patient Outpatient Patient is Housebound

Referral discussed and agreed with patient Carer or Dietitian Name:____________________

Patient’s Name:

Male Female

Address:

Home Tel No:

Mobile Tel No:

CHI:

GPName:

GP Practice/Address/Postcode:

GP is aware of referral? Yes No

Diagnosis:

Reason for Dietetic Referral: How do you think a Dietitian can help?

Adult 16+ please provide a recent height and weight

Height:___________m Current Weight: ________________kg BMI:___________kg/m²

Usual Weight: _________________kg MUST Score______ Weight loss in last 6/12 _______kg

For Infants, Children and Young People 0-16 years, please provide a recent height and weight

Height:___________m Current Weight: ________________kg BMI:___________kg/m² (2-16yr)

Birth Weight ____kg Birth Length: ____cm Gestational Age ____ and recent growth history (add text here)

Past Medical History:Full details of other medical conditions & any recent examinations/tests results.

Children: please include birth measurements & copy of growth chart from Health Visitor or Parent held records

Current Medication: Full list of details required

Carer’s Name & Details if appropriate:

Involvement of other agencies:

Please e-mail referral to: [email protected] or post to: Nutrition & Dietetic Department, Pentland Block, Lynebank Hospital, Dunfermline, KY11 4UW

We will update you and GP of progress with dietetic intervention

Referral to Paediatric Nutrition and Dietetic Department

Appendix 1

mailto:[email protected]


Date: 21 June 2018


16

Appendix 2

Drugs Used for Gastro-oesophageal Reflux

1. Compound alginate preparations Alginate-containing antacids such as Gaviscon Infant increase the viscosity of stomach contents and can protect the oesophageal mucosa from acid reflux.Gaviscon is the only alginate preparation that is suitable for this age group. Recent assessment of Gaviscon Infant on GOR by combined intraluminal impedance/pH questions its efficacy at preventing reflux.

Gaviscon ® infant dual sachets

Birth-2 years (under 4.5kg), 1 dose (half dual sachet) with or after feeds when required, up to 6 times daily.

Birth-2 years (over 4.5kg), 2 doses (one dual sachet) given with or after feeds when required, up to 6 times daily.

Gaviscon Infant should not be given with thickeners or anti-reflux milks. 2. H2 receptor agonists (H2RAs)

Ranitidine works by inhibiting the H2 receptors of the gastric parietal cells. Side effects, although rare, can include fatigue, dizziness, diarrhoea and other gastrointestinal disturbances. Oral ranitidine given 2–3 times a day provides symptomatic and endoscopic symptom improvement in erosive oesophagitis. Tolerance to the antisecretory effect of histamine-2-receptor antagonists develops quickly and the possible occurrence of rebound hypersecretion must be taken into account upon discontinuation of the drug and a reduction in a stepwise manner is recommended. The long-term effects of gastric acid blockade have yet to be determined especially in infants.

Ranitidine syrup 75mg/5mL

1-6 months, 1-3mg/kg three times daily

6 months-18 years, 2-4mg/kg (max 150mg) twice daily. 3. Prokinetics

Domperidone is a peripheral D2 receptor antagonist that increases motility and gastric emptying and decreases the postprandial reflux time. Clinical trials assessing domperidone use in infants or children with GORD are limited. MHRA guidance in 2014 revised the licensed indications for adults and dosages and length of treatment for all age groups for domperidone following a review of safety data across Europe and the finding of an increase in risk of cardiac effects. These effects were observed in patients older than 60 years. As a result the dosage has been reduced and the expectation now is that in infants this treatment would usually be initiated in secondary care (and an ECG would be obtained and cQT interval calculated before commencing treatment).


Date: 21 June 2018


17

Domperidone suspension 5mg/5mL; tablets 10mg

1 month-12 years, 250 micrograms/kg (max 500micrograms/kg) 3 times daily.

4. Proton Pump Inhibitors (PPIs)

Omeparzole, Lansoprazole and Esomeprazole are PPIs that inactivate the H(+)/K(+) –ATPase pump in parietal cells inhibiting gastric acid secretion and increasing the intragastric pH. PPIs are usually well tolerated by patients with the commonest side effects in older patients including mild to moderate headaches, abdominal pain, vomiting and diarrhoea. Occasional electrolyte disturbances and minor reversible elevation of transaminase levels have also been reported. For healing of erosive oesophagitis and relief of GORD symptoms, PPIs are superior to H2RAs with both medications superior to placebo. Administration of long-term acid suppression without a diagnosis is inadvisable. Omeprazole is licensed for use in UK for severe ulcerating reflux oesophagitis in children over 1 year. Stepping down the dose over 2 -3 weeks may avoid the rebound hyperacidity seen when the drug is stopped abruptly.

Omeprazole dispersible tablets 10mg, 20mg

1month-18 years, initially 700micrograms/kg/day increasing to maximum 3mg/kg/day (start at 1mg/kg/day once daily)

Always begin with the MUPS preparation

MUPS tablet to be dissolved in 5-10ml of warm water or in 10ml of sodium bicarbonate 8.4% (allow to stand for 10 minutes prior to administration) or in the older infant it can be mixed with small amount of food eg yoghurt.

There is a considerable difference in cost between the MUPS tablet and the suspension which is rarely indicated.

Lansoprazole is not licensed in children, FasTab® is used more commonly in older children (dose equivalence is 15mg Lansoprazole = 10mg Omeprazole)

For administration by an NG tube or gastrostomy or oral syringe. Can be dispersed in a small amount of warm water.

Esomeprazole gastro resistant granules sachets 10mg, not licensed for use in children 1-11 years

1-11 years (>10kg) 10mg once daily

Used as an alternative to omeprazole MUPS when this is not able to be administered (eg if being given down a jejunal tube)


Date: 21 June 2018


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References

1 Nutrition - enteral nutrition for the preterm infant.

www.gosh.nhs.uk/health-professionals/clinical-guidelines. 2016

2 National Institute for Health and Care Excellence (NICE) Faltering growth: recognition

and management of faltering growth in children.

https://www.nice.org.uk/guidance/ng75 2017

3 Royal College of Paediatrics and Child Health, UK-WHO Growth Charts

https://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-

who-growth-charts

4 National Institute for Health and Care Excellence (NICE) Gastro-oesophageal reflux

disease: recognition, diagnosis and management in children and young people.

https://www.nice.org.uk/guidance/ng1 2015

5 British National Formulary (BNF) for Children. https://www.bnf.org/ 2017-2018.

6 Ainsworth,S, Neonatal Formulary: Drug Use in Pregnancy and The First Year of Life, 7m

Edition, Wiley Blackwell, Oct 2014

7

Logan, L, Purves, J. Diagnosis and Management of Infants with Suspected Cow’s Milk

Allergy. A guide for healthcare professionals working in primary care.

http://www.fifeadtc.scot.nhs.uk/formulary/9-nutrition-and-blood/appendix-9b-

diagnosis-and-management-of-infants-with-suspected-cows-milk-protein-allergy.aspx.

Edited by Laura Logan and Alison MacLeod. February 2016.

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines.%202016

https://www.nice.org.uk/guidance/ng75

https://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-who-growth-charts

https://www.rcpch.ac.uk/child-health/research-projects/uk-who-growth-charts/uk-who-growth-charts

https://www.nice.org.uk/guidance/ng1

https://www.bnf.org/



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